BACKGROUND: Cardiovascular disease (CVD) is the leading cause of mortality among Veterans, and suboptimal risk factor control is an important mechanism for the continued prevalence of CVD. Despite clinic based programming that includes nurse care management, pharmacy support, telephone care programs and intensive quality improvement efforts, CVD risk factors remain sub-optimally controlled among Veterans. Given the high prevalence and cost CVD within the Department of Veterans Affairs, cost-effective mechanisms are needed to manage the burden of prevalent CVD risk factors. Veteran peer health coaches may be one such mechanism; however, previous work has provided limited data of this model with VHA primary care. Previous studies of peer support in non-VHA populations report significant improvement in hypertension control and CVD risk reduction. OBJECTIVES: The proposed project will test the effectiveness of Vet-COACH (Veteran peer Coaches Optimizing and Advancing Cardiac Health), a peer health coaching program to help reduce CVD risk among Veterans. The overall goal of this study is to test the effectiveness of a home-visit peer health coach intervention to promote health behavior change among Veterans with multiple CVD risk factors with a hybrid type 1 implementation study. To target a high risk population, we will focus on Veterans with poorly controlled hypertension and at least one other CVD risk factor. METHODS: We will conduct a randomized controlled trial that will enroll n=590 Veterans to compare a peer health coach intervention consisting of home visits, telephone support, and linkages to appropriate community-based and clinic resources compared to usual VHA primary care. The primary outcome is reduction in systolic blood pressure from baseline to follow-up at 1-year. Secondary outcomes include a reduction in Framingham Cardiovascular risk score, individual cardiovascular risks (tobacco use, lipids), health related quality of life and health cae use. We will also assess the effects of the peer health coach intervention on intermediate outcomes including social support, patient activation, patient/provider communication and health behaviors (e.g. medication adherence, physical activity, nutrition, alcohol use, and stress management). In addition, we will assess the cost of the intervention to inform feasibility for future studies, determine Veteran and staff satisfaction with the intervention, and identify barriers and facilitators to adoption. IMPACT ON VETERANS HEALTH CARE: Integrating peer health coaches into PACT primary care teams may improve the VA's ability to provide community outreach to Veterans. CVD risk reduction provides an ideal target for intervention given the prevalence of modifiable risks among Veterans. The proposed study will increase understanding of the utilization of peer support within PACT teams. If this study proves the main hypothesis, this evidence-based support model could be tested more widely among Veterans with other chronic conditions to improve health outcomes.